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201712349

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IP - IR - Pre Percutaneous Sclerotherapy - Adult - Preprocedure [3674]

IP - IR - Pre Percutaneous Sclerotherapy - Adult - Preprocedure [3674] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Radiology


IP - IR - Pre Percutaneous Sclerotherapy - Adult - Preprocedure [3674]
Intended for Adult Patients Only
Patient Care Orders
Vital Signs [142885]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
On arrival.
Patient Monitoring [142886]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Place in *** foot or *** hand after patient anesthetized.
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes in
the new order.
Type: Indwelling Single Lumen
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Nutrition [143328]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
May have clear liquid diet up to 4 hours prior to
procedure as per anesthesia guidelines for
outpatients.
Intake and Output [142888]
Void Prior to Transport [NURELM0061] ONCE For 1 Occurrences, Void prior to transport.
Non-Categorized Patient Care Orders [106741]
Nursing Communication [NURCOM0022] ONCE, Procedure to be performed ***.
For Diabetic Patients [142889]
Glucose, POC [IPGLUCOSE] CONDITIONAL For 5 Occurrences, Routine, Glucose,
POC should always be ordered in conjunction with
orders for hypoglycemia management and monitoring
as indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition? On Arrival and every
60 minutes for prior glucose less than 60 or greater
than 300 mg/dL.
Page 1 of 4
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 10:55:51 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

GLUCOSE [GLU] CONDITIONAL For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Obtain if POC glucose
less than 40 mg/dL or greater than 400 mg/dL.
Contingency Parameters [106742]
Notify Interventional Radiology Provider
[NURCOM0001]
Provider to Notify: Provider
If systolic blood pressure > (mmHg): 180
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg): 100
If diastolic blood pressure < (mmHg): 60
If temperature > (C):
If temperature < (C):
If heart rate > (bpm): 120
If heart rate < (bpm): 50
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 300
If blood glucose < (mg/dL): 90
If pain score >:
Pulse Oximetry < (%):
If urine output < (mL):
Other: International normalized ratio (INR) is greater
than 1.5,Platelet count is less than 50,000/microliter
Intravenous Therapy
Premedications for Needle Insertion [124125]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is immediate.
lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
IV Fluids [106712]
sodium chloride 0.9% infusion [64367] at 150 mL/hr, Intravenous, CONTINUOUS
Surgical Prophylaxis - Skin Procedure
First Line (Single Response) [230529]
cefazolin (ANCEF) intraVENOUS - Patients who
are 40 - 120 kg [800000]
2 g, Intravenous, ONCE For 1 Doses
cefazolin (ANCEF) intraVENOUS - Patients who
are 121 kg or greater [800000]
3 g, Intravenous, ONCE For 1 Doses
Documented MRSA or history of MRSA or MRSE risk (Single Response) [229228]
Page 2 of 4
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 10:55:51 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Patients who are 40 - 120 kg [228254]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ONCE For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ONCE For 1 Doses
Patients who are 121 kg or greater [228255]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ONCE For 1 Doses
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg/dose [800084]
20 mg/kg, Intravenous, ONCE For 1 Doses
Patients with IgE-mediated or severe reaction to beta-lactam (Single Response) [231905]
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 40-80 kg [800033]
600 mg, Intravenous, ONCE For 1 Doses
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 81-120 kg [800033]
900 mg, Intravenous, ONCE For 1 Doses
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 121 kg and greater [800033]
1,200 mg, Intravenous, ONCE For 1 Doses
Patients with IgE-mediated or severe reaction to beta-lactam AND MRSA or history of MRSA or MRSE
risk (Single Response) [231899]
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 40-80 kg [800033]
600 mg, Intravenous, ONCE For 1 Doses
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 81-120 kg [800033]
900 mg, Intravenous, ONCE For 1 Doses
clindamycin (CLEOCIN) intraVENOUS - Patients
who are 121 kg and greater [800033]
1,200 mg, Intravenous, ONCE For 1 Doses
Surgical Prophylaxis - Intra-oral Procedure
First Line [231901]
penicillin G SODIUM intraVENOUS [800069] 2 Million Units, Intravenous, ONCE For 1 Doses
Patients with IgE-mediated or severe reaction to beta-lactam (Single Response) [231902]
metRONIDazole (FLAGYL) intraVENOUS -
Patients who are 40-120 kg [800062]
500 mg, Intravenous, ONCE For 1 Doses
metRONIDazole (FLAGYL) intraVENOUS -
Patients who are 121 kg and greater [800062]
750 mg, Intravenous, ONCE For 1 Doses
Medications
General [106714]
alcohol dehydrated 98% injection [34323] 5 mL, Other, ON CALL For 1 Doses
For percutaneous administration only, NOT for IV
use. Send to Interventional Radiology
dexamethasone (DECADRON) intraVENOUS
[800037]
10 mg, Intravenous, ON CALL For 1 Doses
microfibrillar collagen (AVITENE) powder [45755] Topical, ONCE For 1 Doses
MD to apply to affected area post sclerotherapy
treatment
sodium tetradecyl (SOTRADECOL) 1% vial
[42234]
Other, ON CALL For 1 Doses
For percutaneous administration only, NOT for IV
use. Send to Interventional Radiology RN to document
total dose given in treatment session.
sodium tetradecyl (SOTRADECOL) 3% vial
[46605]
Other, ON CALL For 1 Doses
For percutaneous administration only, NOT for IV
use. Send to Interventional Radiology RN to document
total dose given in treatment session.
Page 3 of 4
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 10:55:51 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

doxycycline (VIBRAMYCIN) vial RADIOLOGY
ONLY [785170]
Other, ON CALL For 1 Doses
Do not reconstitute. For percutaneous administration
only, NOT for IV use. Send to Interventional
Radiology RN to document total dose given in
treatment session.
lidocaine (STERILE UROJECT) 2% gel 20 mL
[785049]
Urethral, ONCE For 1 Doses
Laboratory
Laboratory [106743]
HEMATOCRIT [HCT] STAT For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PLATELET COUNT [PLT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL [HEMO] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ELECTROLYTES [LYTE] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HCG, QUALITATIVE, URINE [UPREG] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
D-DIMER, QUANT [GM1332] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 4 of 4
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 10:55:51 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org